Mortality and risk factors of disease in Nepal: Trend and projections from 1990 to 2040

BACKGROUND

Between 1990 and 2017, Nepal experienced a shift in the burden of disease from communicable, maternal, neonatal and nutritional (CMNN) diseases to non-communicable diseases (NCDs). With an increasing ageing population and life-style changes including tobacco use, harmful alcohol consumption, unhealthy diets, and insufficient physical activity, the proportion of total deaths from NCDs will continue to increase. An analysis of current diseases pattern and projections of the trends informs planning of health interventions. This analysis aims to project the mortality and risk factor of disease until 2040, based on past trends.

METHODS

This study uses secondary data from the Global Burden of Disease (GBD) Study which analyses historic data from 1990 to 2016 to predict key variables such as, the mortality rates, life expectancy and Years of Life Lost for different causes of death from 2017 to 2040. 'GBD Foresight Visualization', a visualisation tool publicly available in the webpage of Institute for Health Metrics and Evaluation was the source of data for this analysis. GBD forecasting uses three-component modelling process: the first component captures variations due to risk factors and interventions, the second takes into consideration the variation due to measures of development quantified as social development index and the third uses an autoregressive integrated moving average model to capture the unexplained component correlated over time. We extracted Nepal specific data from it and reported number of deaths, mortality rates (per 100,000 population) as well as causes of death for the period 1990 to 2040.

RESULTS

In 1990, CMNN diseases were responsible for approximately two-thirds (63.6%) of total deaths in Nepal. The proportion of the deaths from the CMNN diseases has reduced to 26.8% in 2015 and is estimated to be about a fifth of the 1990 figure (12.47%) in 2040. Conversely, deaths from NCDs reflect an upward trend. NCDs claimed a third of total deaths (29.91%) in the country in 1990, while in 2015, were responsible for about two-thirds of the total deaths (63.31%). In 2040, it is predicted that NCDs will contribute to over two-thirds (78.64%) of total deaths in the country. Less than a tenth (6.49%) of the total deaths in Nepal in 1990 were associated with injuries which increased to 13.04% in 2015 but is projected to decrease to 8.89% in 2040. In 1990, metabolic risk factors including high systolic blood pressure, high total cholesterol, high fasting plasma glucose, high body mass index and impaired kidney functions collectively contributed to a tenth of the total deaths (10.38%) in Nepal, whereas, in 2040 more than a third (37.31%) of the total deaths in the country could be attributed to it.

CONCLUSION

A reverse of the situation in 1990, NCDs are predicted to be the leading cause of deaths and metabolic risk factors are predicted to contribute to the highest proportion of deaths in 2040. NCDs could demand a major share of resources within the health sector requiring extensive multi-sectoral prevention measures, re-allocation of resources and re-organisation of the health system to cater for long-term care.

Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies

BACKGROUND

With global survival increasing for children younger than 5 years of age, attention is required to reduce the approximately 1 million deaths of children aged 5-14 years occurring every year. Causes of death at these ages remain poorly documented. We aimed to explore trends in mortality by causes of death in India, China, Brazil, and Mexico, which are home to about 40% of the world's children aged 5-14 years and experience more than 200 000 deaths annually at these ages.

METHODS

We examined data on 244 401 deaths in children aged 5-14 years from four nationally representative data sources that obtained direct distributions of causes of death: the Indian Million Death Study, the Chinese Disease Surveillance Points, mortality data from the Mexican Instituto Nacional de Estadística y Geografía, and mortality data from the Brazilian Institute of Geography and Statistics. We present data on 12 main disease groups in all countries, with breakdown by communicable and nutritional diseases, non-communicable diseases, injuries, and ill-defined causes. To calculate age-specific and sex-specific death rates for each cause, we applied the national cause of death distribution to the UN mortality envelopes for 2005-16 for each country.

FINDINGS

Unlike Brazil, China, and Mexico, communicable diseases still account for nearly half of deaths in India in children aged 5-14 years (73 920 [46·1%] of 160 330 estimated deaths in 2016). In 2016, India had the highest death rates in nearly every category, including from communicable diseases. Fast declines among girls in communicable disease mortality narrowed the gap by 2016 with boys in India (32·6 deaths per 100 000 girls vs 26·2 per 100 000 boys) and China (1·7 vs 1·5). In China, injuries accounted for the greatest proportions of deaths (20 970 [53·2%] of 39 430 estimated deaths, in which drowning was a leading cause). The homicide death rate at ages 10-14 years was higher for boys than for girls in Brazil, increasing annually by an average of 0·7% (0·3-1·1). In India and China, the suicide death rates were higher for girls than for boys at ages 10-14 years. By contrast, in Mexico it was higher for boys than for girls, increasing annually by an average of 2·8% (2·0-3·6). Deaths from transport injuries, drowning, and cancer are common in all four countries, with transport accidents among the top three causes of death for both sexes in all countries, except for Indian girls, and cancer in the top three causes for both sexes in Mexico, Brazil, and China.

INTERPRETATION

Most of the deaths that occurred between 2005 and 2016 in children aged 5-14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required.

FUNDING

WHO and the University of Toronto Connaught Global Challenge.

Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories

BACKGROUND

Understanding potential trajectories in health and drivers of health is crucial to guiding long-term investments and policy implementation. Past work on forecasting has provided an incomplete landscape of future health scenarios, highlighting a need for a more robust modelling platform from which policy options and potential health trajectories can be assessed. This study provides a novel approach to modelling life expectancy, all-cause mortality and cause of death forecasts -and alternative future scenarios-for 250 causes of death from 2016 to 2040 in 195 countries and territories.

METHODS

We modelled 250 causes and cause groups organised by the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) hierarchical cause structure, using GBD 2016 estimates from 1990-2016, to generate predictions for 2017-40. Our modelling framework used data from the GBD 2016 study to systematically account for the relationships between risk factors and health outcomes for 79 independent drivers of health. We developed a three-component model of cause-specific mortality: a component due to changes in risk factors and select interventions; the underlying mortality rate for each cause that is a function of income per capita, educational attainment, and total fertility rate under 25 years and time; and an autoregressive integrated moving average model for unexplained changes correlated with time. We assessed the performance by fitting models with data from 1990-2006 and using these to forecast for 2007-16. Our final model used for generating forecasts and alternative scenarios was fitted to data from 1990-2016. We used this model for 195 countries and territories to generate a reference scenario or forecast through 2040 for each measure by location. Additionally, we generated better health and worse health scenarios based on the 85th and 15th percentiles, respectively, of annualised rates of change across location-years for all the GBD risk factors, income per person, educational attainment, select intervention coverage, and total fertility rate under 25 years in the past. We used the model to generate all-cause age-sex specific mortality, life expectancy, and years of life lost (YLLs) for 250 causes. Scenarios for fertility were also generated and used in a cohort component model to generate population scenarios. For each reference forecast, better health, and worse health scenarios, we generated estimates of mortality and YLLs attributable to each risk factor in the future.

FINDINGS

Globally, most independent drivers of health were forecast to improve by 2040, but 36 were forecast to worsen. As shown by the better health scenarios, greater progress might be possible, yet for some drivers such as high body-mass index (BMI), their toll will rise in the absence of intervention. We forecasted global life expectancy to increase by 4·4 years (95% UI 2·2 to 6·4) for men and 4·4 years (2·1 to 6·4) for women by 2040, but based on better and worse health scenarios, trajectories could range from a gain of 7·8 years (5·9 to 9·8) to a non-significant loss of 0·4 years (-2·8 to 2·2) for men, and an increase of 7·2 years (5·3 to 9·1) to essentially no change (0·1 years [-2·7 to 2·5]) for women. In 2040, Japan, Singapore, Spain, and Switzerland had a forecasted life expectancy exceeding 85 years for both sexes, and 59 countries including China were projected to surpass a life expectancy of 80 years by 2040. At the same time, Central African Republic, Lesotho, Somalia, and Zimbabwe had projected life expectancies below 65 years in 2040, indicating global disparities in survival are likely to persist if current trends hold. Forecasted YLLs showed a rising toll from several non-communicable diseases (NCDs), partly driven by population growth and ageing. Differences between the reference forecast and alternative scenarios were most striking for HIV/AIDS, for which a potential increase of 120·2% (95% UI 67·2-190·3) in YLLs (nearly 118 million) was projected globally from 2016-40 under the worse health scenario. Compared with 2016, NCDs were forecast to account for a greater proportion of YLLs in all GBD regions by 2040 (67·3% of YLLs [95% UI 61·9-72·3] globally); nonetheless, in many lower-income countries, communicable, maternal, neonatal, and nutritional (CMNN) diseases still accounted for a large share of YLLs in 2040 (eg, 53·5% of YLLs [95% UI 48·3-58·5] in Sub-Saharan Africa). There were large gaps for many health risks between the reference forecast and better health scenario for attributable YLLs. In most countries, metabolic risks amenable to health care (eg, high blood pressure and high plasma fasting glucose) and risks best targeted by population-level or intersectoral interventions (eg, tobacco, high BMI, and ambient particulate matter pollution) had some of the largest differences between reference and better health scenarios. The main exception was sub-Saharan Africa, where many risks associated with poverty and lower levels of development (eg, unsafe water and sanitation, household air pollution, and child malnutrition) were projected to still account for substantive disparities between reference and better health scenarios in 2040.

INTERPRETATION

With the present study, we provide a robust, flexible forecasting platform from which reference forecasts and alternative health scenarios can be explored in relation to a wide range of independent drivers of health. Our reference forecast points to overall improvements through 2040 in most countries, yet the range found across better and worse health scenarios renders a precarious vision of the future-a world with accelerating progress from technical innovation but with the potential for worsening health outcomes in the absence of deliberate policy action. For some causes of YLLs, large differences between the reference forecast and alternative scenarios reflect the opportunity to accelerate gains if countries move their trajectories toward better health scenarios-or alarming challenges if countries fall behind their reference forecasts. Generally, decision makers should plan for the likely continued shift toward NCDs and target resources toward the modifiable risks that drive substantial premature mortality. If such modifiable risks are prioritised today, there is opportunity to reduce avoidable mortality in the future. However, CMNN causes and related risks will remain the predominant health priority among lower-income countries. Based on our 2040 worse health scenario, there is a real risk of HIV mortality rebounding if countries lose momentum against the HIV epidemic, jeopardising decades of progress against the disease. Continued technical innovation and increased health spending, including development assistance for health targeted to the world's poorest people, are likely to remain vital components to charting a future where all populations can live full, healthy lives.

FUNDING

Bill & Melinda Gates Foundation.

Seasonal variations of U.S. mortality rates: Roles of solar ultraviolet-B doses, vitamin D, gene exp ression, and infections

Death rates in the U.S. show a pronounced seasonality. The broad seasonal variation shows about 25% higher death rates in winter than in summer with an additional few percent increase associated with the Christmas and New Year's holidays. A pronounced increase in death rates also starts in mid-September, shortly after the school year begins. The causes of death with large contributions to the observed seasonality include diseases of the circulatory system; the respiratory system; the digestive system; and endocrine, nutritional, and metabolic diseases. Researchers have identified several factors showing seasonal variation that could possibly explain the seasonal variations in mortality rate. These factors include seasonal variations in solar ultraviolet-B(UVB) doses and serum 25-hydroxyvitamin D [25(OH)D] concentrations, gene expression, ambient temperature and humidity, UVB effects on environmental pathogen load, environmental pollutants and allergens, and photoperiod (or length of day). The factors with the strongest support in this analysis are seasonal variations in solar UVB doses and 25(OH)D concentrations. In the U.S., population mean 25(OH)D concentrations range from 21ng/mL in March to 28ng/mL in August. Measures to ensure that all people had 25(OH)D concentrations >36ng/mL year round would probably reduce death rates significantly.

Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Monitoring levels and trends in premature mortality is crucial to understanding how societies can address prominent sources of early death. The Global Burden of Disease 2016 Study (GBD 2016) provides a comprehensive assessment of cause-specific mortality for 264 causes in 195 locations from 1980 to 2016. This assessment includes evaluation of the expected epidemiological transition with changes in development and where local patterns deviate from these trends.

METHODS

We estimated cause-specific deaths and years of life lost (YLLs) by age, sex, geography, and year. YLLs were calculated from the sum of each death multiplied by the standard life expectancy at each age. We used the GBD cause of death database composed of: vital registration (VR) data corrected for under-registration and garbage coding; national and subnational verbal autopsy (VA) studies corrected for garbage coding; and other sources including surveys and surveillance systems for specific causes such as maternal mortality. To facilitate assessment of quality, we reported on the fraction of deaths assigned to GBD Level 1 or Level 2 causes that cannot be underlying causes of death (major garbage codes) by location and year. Based on completeness, garbage coding, cause list detail, and time periods covered, we provided an overall data quality rating for each location with scores ranging from 0 stars (worst) to 5 stars (best). We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to generate estimates for each location, year, age, and sex. We assessed observed and expected levels and trends of cause-specific deaths in relation to the Socio-demographic Index (SDI), a summary indicator derived from measures of average income per capita, educational attainment, and total fertility, with locations grouped into quintiles by SDI. Relative to GBD 2015, we expanded the GBD cause hierarchy by 18 causes of death for GBD 2016.

FINDINGS

The quality of available data varied by location. Data quality in 25 countries rated in the highest category (5 stars), while 48, 30, 21, and 44 countries were rated at each of the succeeding data quality levels. Vital registration or verbal autopsy data were not available in 27 countries, resulting in the assignment of a zero value for data quality. Deaths from non-communicable diseases (NCDs) represented 72·3% (95% uncertainty interval [UI] 71·2-73·2) of deaths in 2016 with 19·3% (18·5-20·4) of deaths in that year occurring from communicable, maternal, neonatal, and nutritional (CMNN) diseases and a further 8·43% (8·00-8·67) from injuries. Although age-standardised rates of death from NCDs decreased globally between 2006 and 2016, total numbers of these deaths increased; both numbers and age-standardised rates of death from CMNN causes decreased in the decade 2006-16-age-standardised rates of deaths from injuries decreased but total numbers varied little. In 2016, the three leading global causes of death in children under-5 were lower respiratory infections, neonatal preterm birth complications, and neonatal encephalopathy due to birth asphyxia and trauma, combined resulting in 1·80 million deaths (95% UI 1·59 million to 1·89 million). Between 1990 and 2016, a profound shift toward deaths at older ages occurred with a 178% (95% UI 176-181) increase in deaths in ages 90-94 years and a 210% (208-212) increase in deaths older than age 95 years. The ten leading causes by rates of age-standardised YLL significantly decreased from 2006 to 2016 (median annualised rate of change was a decrease of 2·89%); the median annualised rate of change for all other causes was lower (a decrease of 1·59%) during the same interval. Globally, the five leading causes of total YLLs in 2016 were cardiovascular diseases; diarrhoea, lower respiratory infections, and other common infectious diseases; neoplasms; neonatal disorders; and HIV/AIDS and tuberculosis. At a finer level of disaggregation within cause groupings, the ten leading causes of total YLLs in 2016 were ischaemic heart disease, cerebrovascular disease, lower respiratory infections, diarrhoeal diseases, road injuries, malaria, neonatal preterm birth complications, HIV/AIDS, chronic obstructive pulmonary disease, and neonatal encephalopathy due to birth asphyxia and trauma. Ischaemic heart disease was the leading cause of total YLLs in 113 countries for men and 97 countries for women. Comparisons of observed levels of YLLs by countries, relative to the level of YLLs expected on the basis of SDI alone, highlighted distinct regional patterns including the greater than expected level of YLLs from malaria and from HIV/AIDS across sub-Saharan Africa; diabetes mellitus, especially in Oceania; interpersonal violence, notably within Latin America and the Caribbean; and cardiomyopathy and myocarditis, particularly in eastern and central Europe. The level of YLLs from ischaemic heart disease was less than expected in 117 of 195 locations. Other leading causes of YLLs for which YLLs were notably lower than expected included neonatal preterm birth complications in many locations in both south Asia and southeast Asia, and cerebrovascular disease in western Europe.

INTERPRETATION

The past 37 years have featured declining rates of communicable, maternal, neonatal, and nutritional diseases across all quintiles of SDI, with faster than expected gains for many locations relative to their SDI. A global shift towards deaths at older ages suggests success in reducing many causes of early death. YLLs have increased globally for causes such as diabetes mellitus or some neoplasms, and in some locations for causes such as drug use disorders, and conflict and terrorism. Increasing levels of YLLs might reflect outcomes from conditions that required high levels of care but for which effective treatments remain elusive, potentially increasing costs to health systems.

FUNDING

Bill & Melinda Gates Foundation.

Trends, causes, and risk factors of mortality among children under 5 in Ethiopia, 1990-2013: findings from the Global Burden of Disease Study 2013

BACKGROUND

Ethiopia has made remarkable progress in reducing child mortality over the last two decades. However, the under-5 mortality rate in Ethiopia is still higher than the under-5 mortality rates of several low- and middle-income countries (LMIC). On the other hand, the patterns and causes of child mortality have not been well investigated in Ethiopia. The objective of this study was to investigate the mortality trend, causes of death, and risk factors among children under 5 in Ethiopia during 1990-2013.

METHODS

We used Global Burden of Disease (GBD) 2013 data. Spatiotemporal Gaussian Process Regression (GPR) was applied to generate best estimates of child mortality with 95% uncertainty intervals (UI). Causes of death by age groups, sex, and year were measured using Cause of Death Ensemble modeling (CODEm). For estimation of HIV/AIDS mortality rate, the modified UNAIDS EPP-SPECTRUM suite model was used.

RESULTS

Between 1990 and 2013 the under-5 mortality rate declined from 203.9 deaths/1000 live births to 74.4 deaths/1000 live births with an annual rate of change of 4.6%, yielding a total reduction of 64%. Similarly, child (1-4 years), post-neonatal, and neonatal mortality rates declined by 75%, 64%, and 52%, respectively, between 1990 and 2013. Lower respiratory tract infection (LRI), diarrheal diseases, and neonatal syndromes (preterm birth complications, neonatal encephalopathy, neonatal sepsis, and other neonatal disorders) accounted for 54% of the total under-5 deaths in 2013. Under-5 mortality rates due to measles, diarrhea, malaria, protein-energy malnutrition, and iron-deficiency anemia declined by more than two-thirds between 1990 and 2013. Among the causes of under-5 deaths, neonatal syndromes such as sepsis, preterm birth complications, and birth asphyxia ranked third to fifth in 2013. Of all risk-attributable deaths in 1990, 25% of the total under-5 deaths (112,288/435,962) and 48% (112,288/232,199) of the deaths due to diarrhea, LRI, and other common infections were attributable to childhood wasting. Similarly, 19% (43,759/229,333) of the total under-5 deaths and 45% (43,759/97,963) of the deaths due to diarrhea and LRI were attributable to wasting in 2013. Of the total diarrheal disease- and LRI-related deaths (n = 97,963) in 2013, 59% (57,923/97,963) of them were attributable to unsafe water supply, unsafe sanitation, household air pollution, and no handwashing with soap.

CONCLUSIONS

LRI, diarrheal diseases, and neonatal syndromes remain the major causes of under-5 deaths in Ethiopia. These findings call for better-integrated newborn and child survival interventions focusing on the main risk factors.

Avoiding 40% of the premature deaths in each country, 2010-30: review of national mortality trends to help quantify the UN sustainable development goal for health

BACKGROUND

The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence governments. We propose, as a quatitative health target, "Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages". Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50-69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide.

METHODS

UN sources yielded overall 1970-2010 mortality trends. WHO sources yielded cause-specific 2000-10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third.

RESULTS

Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970-2010, particularly in childhood. From 2000-10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000-10) were: 34% at ages 0-4 years; 17% at ages 5-49 years; 15% at ages 50-69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide).

INTERPRETATION

Moderate acceleration of the 2000-10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0-49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0-69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic.

FUNDING

UK Medical Research Council, Norwegian Agency for Development Cooperation, Centre for Global Health Research, and Bill & Melinda Gates Foundation.

[New classification of causes of mortality of nutritional origin by means of the Delphi method]

The causes of mortality of nutritional origin (MNO) are not classified in the consecutive reviews of the international disease classification (IDC) and there is no agreement for their most proper classification. The objective of this study is to elaborate, using the last ICD as a guide, a list of causes of mortality of nutritional origin which will be used as a reference in future studies. A two round Delphi method was organized with an expert's consenssus in clinical nutrition. The experts were asked to classify a list of causes of MNO in 4 groups; 1) group A: congenital errors related to nutrition, 2) group B: Causes associated with other pathologies, 3) group 3: Excess and defect nutrition disorders, and 4) excluded. In total, 86 causes of MNO were taken under the consensus of experts, and 79 (91.9%) came to an agreement. 14 (17.7%) causes were classified in group A, 5 (6.3%) causes in group B, 37 (46.8%) causes in group C and 23 (29.1%) were excluded. This is a first approach to the classification of mortality causes of nutritional origin, probably due to the ambiguity and disparity of opinions between experts with respect to these causes. This new classification will be very useful due to the fact that it will enable homogenization of the studies and that way we will have comparable studies, using it as a clarifier annex for the ICD of the moment.

Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial

BACKGROUND

nasogastric tube (NGT) feeding is commonly used after stroke, but its effectiveness is limited by frequent dislodgement.

OBJECTIVE

the objective of the study was to evaluate looped NGT feeding in acute stroke patients with dysphagia.

METHODS

this was a randomised controlled trial of 104 patients with acute stroke fed by NGT in three UK stroke units. NGT was secured using either a nasal loop (n = 51) or a conventional adhesive dressing (n = 53). The main outcome measure was the proportion of prescribed feed and fluids delivered via NGT in 2 weeks post-randomisation. Secondary outcomes were frequency of NGT insertions, treatment failure, tolerability, adverse events and costs at 2 weeks; mortality; length of hospital stay; residential status; and Barthel Index at 3 months.

RESULTS

participants assigned to looped NGT feeding received a mean 17% (95% confidence interval 5-28%) more volume of feed and fluids, required fewer NGTs (median 1 vs 4), and had fewer electrolyte abnormalities than controls. There was more minor nasal trauma in the loop group. There were no differences in outcomes at 3 months. Looped NGT feeding cost 88 pounds sterling more per patient over 2 weeks than controls.

CONCLUSION

looped NGT feeding improves delivery of feed and fluids and reduces NGT reinsertion with little additional cost.

Mortality profiles in a country facing epidemiological transition: an analysis of registered data

BACKGROUND

Sub-national analyses of causes of death and time-trends help to define public health policy priorities. They are particularly important in countries undergoing epidemiological transition like Peru. There are no studies exploring Peruvian national and regional characteristics of such epidemiological transition. We aimed to describe Peru's national and regional mortality profiles between 1996 and 2000.

METHODS

Registered mortality data for the study period were corrected for under-registration following standardized methods. Main causes of death by age group and by geographical region were determined. Departmental mortality profiles were constructed to evaluate mortality transition, using 1996 data as baseline. Annual cumulative slopes for the period 1996-2000 were estimated for each department and region.

RESULTS

For the study period non-communicable diseases explained more than half of all causes of death, communicable diseases more than one third, and injuries 10.8% of all deaths. Lima accounted for 32% of total population and 20% of total deaths. The Andean region, with 38% of Peru's population, accounted for half of all country deaths. Departmental mortality predominance shifted from communicable diseases in 1996 towards non-communicable diseases and injuries in 2000. Maternal and perinatal conditions, and nutritional deficiencies and nutritional anaemia declined markedly in all departments and regions. Infectious diseases decreased in all regions except Lima. In all regions acute respiratory infections are a leading cause of death, but their proportion ranged from 9.3% in Lima and Callao to 15.3% in the Andean region. Tuberculosis and injuries ranked high in Lima and the Andean region.

CONCLUSION

Peruvian mortality shows a double burden of communicable and non-communicable, with increasing importance of non-communicable diseases and injuries. This challenges national and sub-national health system performance and policy making.

Epidemiologic transition in an isolated indigenous community in the Valley of Oaxaca, Mexico

The objective of the present study is to analyze age-specific mortality in a rural indigenous community in the throes of a secular increase in size in the Valley of Oaxaca, southern Mexico, over 30 years, 1970-1999. Variation in mortality by age group was analyzed over time for evidence of an epidemiological transition. The seasonal rain pattern in the Valley of Oaxaca (83% from May through September) was evaluated for its relationship with mortality in wet and dry months. Mortality and causes of death changed markedly over the 30-year interval. Infant and preschool mortality, overall mortality, and causes of death changed from the 1970s through the 1990s. Prereproductive deaths (<15 years) predominated in the 1970s and were largely due to gastrointestinal and respiratory diseases, with periodic outbreaks of measles. Deaths of adults 65+ years predominated in the 1990s and were largely due to degenerative diseases usually associated with aging. The marked changes in age and causes of death over the three decades (epidemiologic transition from Stage I to Stage II) occurred concurrently with significant secular increases in body size in children, adolescents, and young adults, highlighting improved health and nutritional conditions in the community which is in early Stage II of the demographic transition. The demographic transition to Stage II is a leading indicator (15-25 years lag) for the onset of the secular trend, while the epidemiologic transition to Stage II is a predictor that the secular increase is in process in the study community.

Malnutrition is an independent predictor of 1-year mortality following acute illness

Four hundred and forty-five randomly selected hospitalised patients had their nutritional status assessed from anthropometric, haematological and biochemical data. Nutritional status was compared between survivors and non-survivors at baseline, 6 weeks and 6 months. Using Cox's proportional hazard analysis, we measured the association between nutritional assessment variables and 1-year mortality after adjusting for disability, chronic illness, medications, smoking and tissue inflammation. Nutritional status was significantly worse amongst non-survivors compared with survivors, and non-survivors showed marked and significant deterioration in all measures of nutritional status compared with survivors. After adjusting for poor prognostic indicators the hazard ratios of death in the fourth, third and second quarters of both baseline serum albumin and mid-upper arm circumference distributions relative to the first were 0.68, 0.77 and 0.58 (trend P = 0.013) and 0.61, 1.0 and 0.87 (trend P = 0.005) respectively. Intervention studies are needed to determine whether the relationship between malnutrition and the poor outcome highlighted by the present study is causal or a mere association.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: October 2006

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-five studies (37 comparisons) met the inclusion criteria with 2648 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. Significant improvements in weight at three months were found for groups receiving dietary advice plus nutritional supplements compared with dietary advice alone, WMD 1.68 kg (95% CI 0.14 to 3.21) or no additional advice, WMD 1.97 (95% CI 0.07 to 3.86). There were significant improvements in grip strength and mid-arm muscle circumference in the advice plus supplement groups compared with dietary advice alone. It is uncertain whether nutritional supplements and dietary advice produce the same effects. No significant differences were found between groups for clinical outcomes. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

Ethnic disparities in nutrition-related mortality in New Zealand: 1997-2011

AIMS

To estimate the mortality due to non-optimal levels of systolic blood pressure, total blood cholesterol, body mass index (BMI), and vegetable and fruit intake amongst Maori and non-Maori in New Zealand in 1997. In addition, to estimate the ethnic-specific burden of disease that could potentially be avoided in 2011 if exposure to these risk factors were reduced.

METHODS

The study uses comparative risk assessment methodology, a systematic approach to estimating both attributable and avoidable burden of disease developed by the World Health Organization.

RESULTS

About 47% of deaths among Maori and 39% of deaths among non-Maori were estimated to be due to the selected risk factors. Age-standardised mortality rates for attributable ischaemic heart disease burden were consistently higher in Maori for individual risk factors. Age standardised mortality attributable to BMI was relatively higher for Maori, especially diabetes mortality. Estimates of avoidable mortality suggest that the health gains for Maori would be relatively greater than for non-Maori across all risk factors, but particularly with improvements in BMI.

CONCLUSIONS

Non-optimal levels of systolic blood pressure, cholesterol, BMI, and to a lesser extent vegetable and fruit intake are major modifiable causes of death in New Zealand. Small changes in risk factor levels could have a major impact on population health within a decade, with relatively greater health gains for Maori.

Obstruction in patients with colorectal cancer increases morbidity and mortality in association with altered nutritional status

Intestinal obstruction aggravates the prognosis of colorectal cancer (CRC) patients. The aim of this study was to carry out a comparative analysis of nutritional status and inflammatory response in CRC patients with or without intestinal obstruction. The study was carried out on 43 patients with CRC. Twenty-three of these patients had intestinal obstruction. Anthropometric measurements, serum protein content, acute phase reactants, and diagnostic and risk nutritional indices were analyzed. The presence of intestinal obstruction reduced albumin (31 +/- 5.2 vs. 36 +/- 4.2 g/l; P = 0.0025) and prealbumin (0.13 +/- 0.047 vs. 0.21 +/- 0.042 g/l; P = 0.0001) and increased C-reactive protein (49 +/- 43.8 vs. 14 +/- 16.7 mg/l; P = 0.006) and alpha1-antitrypsin (189 +/- 34.7 vs. 148 +/- 35.4 mg/dl; P = 0.0011). Intestinal obstruction was related to malnutrition (86% vs. 33%; P = 0.019) and Mullen's prognostic nutritional index (48 +/- 21.7 vs. 31 +/- 17.9; P = 0.038) in CRC patients. Mullen's nutritional risk index was inversely correlated to total cholesterol (r = -0.51; P = 0.0002) and albumin (r = -0.81; P = 0.0001). No correlation was found between Duke's tumor stages and acute phase response, inflammatory parameters, and malnutrition. In conclusion, intestinal obstruction occurred more frequently in CRC patients with malnutrition. The increased morbidity and mortality of CRC patients was also associated with acute phase response, inflammation, and low serum cholesterol and triglyceride concentration.

Nutritional status of outpatients with systemic immunoglobulin light-chain amyloidosis 1

BACKGROUND

Maintenance of a good nutritional status is associated with prolonged survival in many chronic diseases. To date, the nutritional status of outpatients with immunoglobulin light-chain (AL) amyloidosis has not been evaluated.

OBJECTIVE

The aims of this study were to obtain information regarding the nutritional status of AL amyloidosis outpatients and to investigate its prognostic role.

DESIGN

One hundred six consecutive patients with histologically confirmed AL amyloidosis were enrolled. Anthropometric, biochemical, and clinical variables were measured. The Kaplan-Meier method was used to calculate survival. A Cox proportional hazard model was constructed to evaluate the prognostic effect of the nutritional variables.

RESULTS

Unintentional weight loss (median: 11.3%; range: 2.6-34% of usual nonedematous body weight) was documented in 58 subjects (54.7%). Body mass index (BMI; in kg/m2) was <22 in 25 subjects (23.6%). Serum prealbumin was <200 mg/L (lower reference limit) in 26 patients (24.5%). A multivariate analysis showed that the percentage weight loss was significantly greater in patients with than in those without cardiac involvement (P = 0.03), and it also differed significantly by New York Heart Association class (P = 0.02) and Eastern Cooperative Oncology Group performance status (P = 0.001). Cardiac involvement (P = 0.008), hematologic response to therapy (P = 0.013), BMI (P = 0.001) and serum prealbumin (P = 0.001) were independent predictors of survival.

CONCLUSIONS

Malnutrition is a prominent clinical feature of patients with AL amyloidosis. Appropriate nutritional evaluation that comprises the easily measurable nutritional variables associated with survival should be an integral part of the clinical assessment of AL amyloidosis outpatients.

Nutrient analysis of the Guamanian diet: acceptable energy distribution with inadequate nutrient quality

Nutrition-related diseases are now a major health problem and cause of mortality on Guam. The purpose of this study is to document the nutrient content of the diet of adults on Guam with ethnic and sex differences. The subjects were 400 adults residing on Guam selected to reflect the population distribution of the island for ethnicity and gender. A 24-hour dietary recall was administered via telephone using two-dimensional food models. The diets were analyzed for nutrient content using the Food Intake Analysis System. T-tests were used to compare the mean nutrients and a Kruskal-Wallis test was used to compare the median for the two genders. Analysis of variance was used to compare mean nutrient intakes among the ethnic groups. Results show a generally appropriate intake of energy with energy distribution of carbohydrate, protein and fat within guidelines established by the National Academy of Sciences (U. S.). Nutrients that likely exceed recommendations for good health include saturated fat, cholesterol, and sodium with mean (+/- SD) intake at 10.5 +/- 4.1 of kcals, 352 +/- 256 mg/d, and 3226 +/- 1901 mg/d, respectively. Fiber, vitamin A, C, and E, folate, and magnesium are at levels that suggest inadequacy because large proportions of the sample, 96%, 48%, 56%, 83%, 85%, and 74%, respectively, were below the Estimated Adequate Intake (EAR) for these nutrients. Median intake is exceptionally low for calcium, 360 mg/d, and potassium, 2169 mg/d, and large proportions of the sample, 92% and 96%, are below the Adequate Intake (AI) level for calcium and potassium, respectively. This nutrient profile is associated with increased risk for chronic disease.

The disease profile of poverty: morbidity and mortality in northern Uganda in the context of war, population displacement and HIV/AIDS

The population of Gulu District (northern Uganda) has been severely incapacitated by war, epidemics and social disruption. This study is aimed at describing disease patterns and trends in this area through a retrospective analysis of discharge records for 155205 in-patients of Lacor Hospital in the period 1992-2002. The burden of infectious diseases in childhood is overwhelming, with malaria accounting for the steepest increase in admissions. Admissions for war-related injuries and malnutrition fluctuated with the intensity of the war and the severity of famine. Emerging and re-emerging infections, such as HIV/AIDS, tuberculosis and Ebola, accounted for a heavy disease burden; however, there has been a trend for admissions related to HIV/AIDS and tuberculosis to decrease since the implementation of community-based services. Vulnerable groups (infants, children and women) accounted for 79.8% of admissions. Long-term war, population displacement, the collapse of social structures and the breakdown of the health system place people at a much greater risk of persistent, emerging and re-emerging infectious diseases, malnutrition and war-related injuries, shaping the 'disease profile of poverty'. Most of the disease burden results from infectious diseases of childhood, whose occurrence could be dramatically reduced by low-cost and effective preventive and curative interventions.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

[Survival and habitual nutrient intake among elderly men]

The aim of this paper was to determinate whether the intake of energy and nutrients was associated with all-cause mortality in the elderly men of the Warsaw region. Data on the intake of energy and nutrients were collected using a 3-day record method, in spring 1999. The mortality follow-up period lasted until December 31, 2003. During this period 43 men (29.5 % subjects) died. The all-cause mortality was higher among subgroup of elderly men with lower intake of carbohydrates, dietary fiber, vitamin B1, vitamin B6, vitamin PP, potassium, phosphorus, magnesium, zinc, copper and among subgroup of men with lower intake of total fat, saturated and monounsaturated fatty acids.

Dietary advice and nutritional supplements in the management of illness-related malnutrition: systematic review

BACKGROUND AND AIMS

This review investigated whether dietary advice to improve nutritional intake in adults with illness-related malnutrition improved mortality, morbidity, weight and energy intake, and whether oral nutritional supplements gave additional benefit, when given in combination with dietary advice.

METHODS

Systematic review of randomised controlled trials comparing dietary advice with either (i) no advice, (ii) nutritional supplements or (iii) dietary advice plus nutritional supplements, in people with illness-related malnutrition.

RESULTS

Twenty-four trials (25 comparisons) met the inclusion criteria, including 2135 randomised participants. Duration of follow-up ranged from 16 days to 24 months. There was no significant difference in mortality or morbidity for each comparison. Groups receiving supplements gained significantly more weight (or lost significantly less weight) than those who received dietary advice, weighted mean difference 1.09 kg (0.29-1.90) (4 studies). There were no significant differences in weight and energy intake between groups for the other comparisons. Few data were available for other outcomes.

CONCLUSIONS

Nutritional supplements may have a greater role than dietary advice in the short-term improvement of body weight in illness-related malnutrition. There is a lack of evidence to support dietary advice in the management of illness-related malnutrition, but this is based on few, often poor quality, studies.

Receiver operating characteristic analysis of body mass index to detect increased risk of functional morbidity in Vietnamese rural adults

OBJECTIVE

To assess the performance of low BMI, and define optimal BMI cut-off values in order to detect fever-associated adult morbidity.

DESIGN

A cohort study of adults between 18 and 60 y in rural Vietnam, whose BMI and health status were assessed at baseline, and who were then monitored for illness events for 4 months. Nonparametric receiver operating characteristic (ROC) analysis was used to evaluate the performance of low BMI to detect the average number of restricted-days due to illness and to determine optimal cut-off values.

SETTING

A rural commune in the Red River Delta, northern Vietnam.

SUBJECTS

The study included 693 men and 739 women aged 18-60-y.

RESULTS

At baseline, 21% of the study participants had a BMI<18.5 kg/m(2). As BMI progressively decreased, the percentage of participants experiencing morbidity with fever increased. The areas under the ROC curves for BMI were significantly greater than 0.5 for all levels of monthly average restricted-days of illness (MARDI) with fever, with best performance for >5 days/month. Excluding participants with acute or chronic disease at baseline improved the performance of BMI to detect MARDI with fever of >5 days (area under ROC curve 0.95; 95% CI 0.92, 0.99). With increasing levels of MARDI with fever, BMI cut-offs fell to 17.9 kg/m(2) when MARDI with fever was >5 days.

CONCLUSIONS

The ROC analysis demonstrates that low BMI performs well as a risk indicator of MARDI with fever of >5 days with an optimal BMI cut-off value of 17.9 kg/m(2).

Factores pronósticos de mortalidad relacionados con el estado nutricional en ancianos hospitalizados

BACKGROUND AND OBJECTIVE

The proportion of elderly patients hospitalized in acute care wards has progressively increased. Patients with a decreased functional status are prone to have malnutrition which negatively affects their prognosis and increases mortality. However, it is unclear whether functional and nutritional status are independent risk factors of mortality.

PATIENTS AND METHOD

We investigated the relation between functional status (Katz index) and nutritional parameters and the incidence of mortality in a prospective, observational study of a cohort of elderly patients who were admitted to an internal medicine ward. Prevalence of malnutrition upon admission and cumulative incidence rate of in-hospital mortality were computed. Also, potential nutritional and functional prognostic factors for in-hospital mortality were identified by multiple logistic regression.

RESULTS

The prevalence of malnutrition in 105 patients included in the cohort was 57.1% (95 percent confidence interval, 47.1% to 66.8%). The incidence of in-hospital mortality was 14.3% (95 percent confidence interval, 8.2% to 22.5%). After adjustment, independent prognostic factors for in-hospital mortality were: a high level of functional dependence (F and G categories of Katz index, OR 6.1; 95 percent confidence interval, 1.4 to 26.3), diminished levels of serum transferrin (each decrement of 1g/L, OR 8.3; 95 percent confidence interval, 3.4 to 20.0) and lymphocyte cell counts (each decrement of 0.5 x 10(9) cells/L, OR 2.3; 95 percent confidence interval, 1.5 to 3.5).

CONCLUSIONS

The prevalence of malnutrition and the incidence of mortality are very high in the hospitalized elderly. In our cohort, decreased serum transferrin and lymphocyte cell count, and an increased level of functional status were associated with an increased risk of in-hospital mortality. Given the high prevalence of geriatric patients in acute care hospitals, strategies to promote an adequate nutrition may reduce the risk of death.

A clinical review of micronutrients in HIV infection

This article reviews current literature on the role of micronutrients in human immunodeficiency virus (HIV) infection. Deficiencies of micronutrients are common in HIV-infected persons. They occur due to malabsorption, altered metabolism, gut infection, and altered gut barrier function. There is a compelling association of deficiencies of micronutrients in HIV-infection with immune deficiency, rapid disease progression, and mortality. Also, there is increased risk of vertical HIV transmission from mother to child with deficiency of vitamin A, and of neurological impairment with vitamin B12. The last five years have been exciting in micronutrient research, and there is promise that some micronutrients may be key factors in maintaining health in HIV immunodeficiency, and in reducing mortality. Selenium appears important in reducing virulence of HIV and slowing disease progression. Vitamin A supplementation in pregnant women with HIV may reduce maternal mortality and improve birth outcomes. Supplementation in children with HIV may accelerate growth. Carotenoid supplementation is being evaluated. Vitamin B12 may slow HIV immune deficiency disease progression, and reverse neurological compromise. Clinical benefit of supplementation with some micronutrients may be measurable in the presence of pre-existing deficiency. Apart from improved general nutrition, the impact of micronutrient supplements on health and their optimal use in HIV infection is controversial because there are so few controlled clinical trials. Further research is needed to elucidate the role of micronutrient deficiencies on the course of HIV infection, and the preventive and therapeutic role of supplementation in its clinical management. Nevertheless, current knowledge supports the use of routine multivitamin and trace element supplementation as adjuvant to conventional antiretroviral drug treatment as a relatively low-cost intervention.

Nutritional indicators, peripheral blood lymphocyte subsets and survival in an institutionalised elderly population

The objectives of this study were to determine the percentage and absolute counts of the peripheral blood lymphocyte subsets, and to examine the relationship between lymphocyte subsets and nutritional status, and total mortality in an institutionalised elderly population. Design The study had a cross-sectional and observational design. The sample of 115 permanent elderly residents was drawn from large geriatric institution in Melbourne, Australia. The main outcome measures were as follows: (i) percentages and absolute counts of lymphocyte subsets, (ii) association between biochemical indices of nutritional status (ferritin, iron and zinc) and peripheral blood lymphocyte subsets, (iii) total mortality during a 22-month period in relation to baseline lymphocyte subset counts. Women had higher absolute counts of various lymphocyte subsets than men. Positive correlations of serum ferritin with the number of CD8 (T-suppressor cell) and of serum iron with CD56 (natural killer, NK cells) were observed in men. In women, serum zinc was positively correlated with the absolute counts of CD3 (total T-cells), CD4 (T-helper cell) and CD19 (total B-cell). The analysis of survival data after 22 months showed that the mean number of CD4 cells of non-survivors (524 +/-292 x10(6)cells/L) was significantly lower than that of survivors (759+/-292 x 10(6) cells/L). The biochemical indicators of iron and zinc status partly account for variations in lymphocyte subset counts, consistent with known effects of iron overload and of zinc deficiency on immunocompetence. The number of CD4 T-cells may be useful in the prediction of total mortality in an institutionalised elderly population.

The global problems of child malnutrition and mortality in different world regions

The study of child mortality occupies a special place in the field of demographic research, since it represents the negative component of population growth. Also, the world food problem has become a familiar topic since the end of the World War II. The idea that population growth will sometime in the future outrun food supplies and universal starvation occurs. This study deals with what happened in global and regional variations regarding the child malnutrition and mortality rates. The main objective of the study is to explain and to explore the effect of the social, demographic, economic and health factors on child malnutrition and mortality rates among different regions in the globe. The study includes ten regions of the whole world compared to other studies that covered only one or two regions. Data were collected from various sources. The sample involved 191 countries. These countries divided by regions of world as following. East Southern Africa, West Africa, East Asia and Pacific, South Asia, Eastern Europe and Central Asia, Europe, Middle East, North Africa, North America, and South America. The results of descriptive analysis show that the highest mean rate of child malnutrition was found in South Asia region (57 children per 100), while the smallest mean rate was found in Europe region (just 1 child per 100). In West Africa region, the average of child mortality rate per 1000, 172 children, was the highest among all regions in the world, while in Europe was found to be 14 children per 1000. The results of correlation coefficients reveal that there were positive associations between illiteracy rate, unemployment, poverty, fertility rate, family size, food consumption, maternal mortality rate, population per physician, and child malnutrition and mortality in the whole world regions. Some regions have strong significant associations, such as Sub-Saharan Africa, Asia, and Americas, and other were non-significant association, such as Europe, Middle East, and North Africa. The results suggest that there were negative associations between GNP, household income, protein consumption, and child malnutrition and mortality in all world regions except Europe and Central Asia regions.

Mortality among displaced former UNITA members and their families in Angola: a retrospective cluster survey

OBJECTIVE

To measure retrospectively mortality among a previously inaccessible population of former UNITA members and their families displaced within Angola, before and after their arrival in resettlement camps after ceasefire of 4 April 2002.

DESIGN

Three stage cluster sampling for interviews. Recall period for mortality assessment was from 21 June 2001 to 15-31 August 2002.

SETTING

Eleven resettlement camps over four provinces of Angola (Bié, Cuando Cubango, Huila, and Malange) housing 149 000 former UNITA members and their families.

PARTICIPANTS

900 consenting family heads of households, or most senior household members, corresponding to an intended sample size of 4500 individuals.

MAIN OUTCOME MEASURES

Crude mortality and proportional mortality, overall and by period (monthly, and before and after arrival in camps).

RESULTS

Final sample included 6599 people. The 390 deaths reported during the recall period corresponded to an average crude mortality of 1.5/10 000/day (95% confidence interval 1.3 to 1.8), and, among children under 5 years old, to 4.1/10 000/day (3.3 to 5.2). Monthly crude mortality rose gradually to a peak in March 2002 and remained above emergency thresholds thereafter. Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%). Most war victims and people who had disappeared were women and children.

CONCLUSIONS

This population of displaced Angolans experienced global and child mortality greatly in excess of normal levels, both before and after the 2002 ceasefire. Malnutrition deaths reflect the extent of the food crisis affecting this population. Timely humanitarian assistance must be made available to all populations in such conflicts.

Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial

BACKGROUND AND PURPOSE

Previous studies suggest that undernourished patients with acute stroke do badly. The data, however, are not robust. We aimed to reliably assess the importance of baseline nutritional status as an independent predictor of long-term outcome after stroke in a large prospective cohort enrolled in the Feed Or Ordinary Diet (FOOD) trial, a multicenter randomized trial evaluating various feeding policies.

METHODS

Patients admitted to hospital with a recent stroke were enrolled in the FOOD trial. Data on nutritional status and other clinical predictors of outcome were collected at trial entry. At 6 months, the coordinating center collected data on survival and functional status (modified Rankin Scale). Outcome assessment was done by researchers blinded to baseline assessments and treatment allocation.

RESULTS

Between November 1996 and November 2001, 3012 patients were enrolled, and 2955 (98%) were followed up. Of the 275 undernourished patients, 102 (37%) were dead by final follow-up compared with only 445 (20%) of 2194 patients of normal nutritional status (odds ratio [OR], 2.32; 95% CI, 1.78 to 3.02). After adjustment for age, prestroke functional state, and stroke severity, this relationship, although weakened, still held (OR, 1.82; 95% CI, 1.34 to 2.47). Undernourished patients were more likely to develop pneumonia, other infections, and gastrointestinal bleeding during their hospital admission than other patients.

CONCLUSIONS

These data provide reliable evidence that nutritional status early after stroke is independently associated with long-term outcome. It supports the rationale for the FOOD trial, which continues to recruit and aims to estimate the effect of different feeding regimes on outcome after stroke and thus determine whether the association observed in this study is likely to be causal.

Body mass index, height, weight, arm circumference, and mortality in rural Bangladeshi women: a 19-y longitudinal study

BACKGROUND

Studies in Western populations report a J- or U-shaped relation between body mass index (BMI; in kg/m(2)) and mortality, in which persons with extremes of BMI experience increased mortality. In contrast, little is known about populations in developing countries, where nutritional status is lower.

OBJECTIVE

The objective was to examine the association between BMI and mortality in Bangladeshi women.

DESIGN

A cohort of 1888 rural Bangladeshi women (mean age: 27.9 y) was followed over 19 y. Height, weight, arm circumference, fertility, and socioeconomic data were obtained between 1975 and 1979. Mortality, loss-to-follow-up, and additional socioeconomic data were identified by the demographic surveillance system of the International Centre for Health and Population Research, Bangladesh. Proportional hazards regression was used to examine the relation between BMI and all-cause mortality.

RESULTS

The association between BMI and mortality was reverse J-shaped. After adjustment for socioeconomic indicators, the risk of dying was highest in women with BMIs in the lowest 10% of the decile distribution (< 16.39) and lowest in women with intermediate (11-89% range of the decile distribution) BMIs (16.39-20.71). Women with BMIs in the highest 10% of the distribution (> 20.71) had slightly elevated mortality (NS) compared with those with intermediate BMIs. Age and education were strongly associated with mortality. Women without schooling had a risk of mortality 4 times that of women with > or = 1 y of schooling.

CONCLUSIONS

A woman's BMI relative to the BMI distribution in the local population may be a better predictor of mortality than is absolute BMI. The contribution of education in reducing mortality supports development programs aimed at increasing women's education.

Changes in child survival are strongly associated with changes in malnutrition in developing countries

Considerable evidence suggests that malnutrition affects human performance, health and survival, including physical growth, morbidity, mortality, cognitive development, reproduction, physical work capacity and risks for several adult-onset chronic diseases. In recent decades, development agencies and governments have emphasized selective interventions to improve health and nutritional status, such as immunizations, oral rehydration, antibiotics and micronutrients, with child survival as a major motivation and justification. Although the efficacy of these approaches for improving child survival has been amenable to study, providing some of the rationale for using these approaches, it has not been possible to test directly the effects of improvements in general malnutrition. The present study quantified the effects of changes in general malnutrition, as measured by child weight-for-age (WA), on changes in child survival in 59 developing countries, using aggregate, longitudinal data at national and subnational levels from 1966 to 1996. Mixed model analysis (in SAS) was used, to take advantage of the multilevel and longitudinal nature of these data sets. Changes in WA have a statistically significant effect on changes in child mortality, independent of socioeconomic and policy changes represented by the secular trend. The secular trend in mortality began earlier and leveled off at higher mortality rates in populations with a higher prevalence of malnutrition. Gaps in coverage of selective interventions are more likely and more serious in the more malnourished populations. Continued reduction in mortality will require improved targeting of selective interventions and general nutritional improvement to the most marginal populations.

Does inflammation or undernutrition explain the low cholesterol-mortality association in high-functioning older persons? MacArthur studies of successful aging

OBJECTIVES

To explore the effect of inflammation and undernutrition on the association between hypocholesterolemia and higher overall mortality in high-functioning older persons.

DESIGN

Prospective cohort study.

SETTING

Three U.S. communities.

PARTICIPANTS

A cohort of 870 participants from the MacArthur Studies of Successful Aging.

MEASUREMENTS

Baseline information was obtained for serum levels of cholesterol, C-reactive protein, interleukin-6, and albumin; body mass index; prevalent medical conditions; health behaviors; and medications. Crude and multivariate logistic regression analyses were used to examine the association between serum total cholesterol levels and 7-year all-cause mortality, while adjusting for potential confounders.

RESULTS

In univariate analysis, the risk ratio of low serum total cholesterol level (<169 mg/dL) for 7-year total mortality was 1.90 (95% confidence interval (CI) = 1.18-3.07). The multiple adjusted risk ratios were 1.82 (95% CI = 1.10-3.00) after controlling for markers of inflammation and nutrition and 1.39 (95% CI = 0.80-2.40) after adjustment for additional cardiovascular risk factors. Sex was an important confounding variable that contributed to the observed inverse association between low serum cholesterol and overall mortality in univariate analysis.

CONCLUSIONS

Hypocholesterolemia is not an independent risk factor for increased overall mortality in high-functioning community-dwelling older men and women. The association between low total cholesterol and high mortality observed in crude analysis is mainly confounded by common cardiovascular risk factors, rather than underlying inflammation or undernutrition.

[A sixteen-year epidemiological profile of a pediatric intensive care unit, Brazil]

OBJECTIVE

To review epidemiological data from patients admitted to a Pediatric Intensive Care Unit (PICU), Brazil, and to compare them to medical aspects associated to disease severity and mortality. Also, to profile these patients, including demographic data, disease prevalence, mortality rates and associated factors.

METHODS

Retrospective data were collected from all patients admitted in a PICU of a university hospital between 1978 and 1994. Data were presented as percentages and compared using Chi-square, and calculating the relative risk (RR) with a 95% confidence interval, p<0.05.

RESULTS

Of 13, 101 patients selected, most of them were boys (58.4%), younger than 12 months of age (40.4%), well-nourished (69.5%), and with clinical disease (73.1%). The general mortality rate was 7.4%. Patients aged less than 12 months showed a RR of 1.86 (CI 1.65 - 2.10; p<0.0001), while the RR of malnutrition was 2.98 (CI 2.64 - 3.36; p<0.0001).

CONCLUSIONS

The epidemiological survey showed that the mortality is higher in malnourished children younger than 12 months of age. Sepsis was the most main cause of death.